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|
Attributes | |
ACN | 789088 |
Time | |
Date | 200805 |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Controlling Facilities | tracon : clt.tracon |
Operator | common carrier : air carrier |
Make Model Name | B737-800 |
Operating Under FAR Part | Part 121 |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : lead technician |
Qualification | technician : airframe technician : powerplant |
Experience | maintenance lead technician : 13 maintenance technician : 8 |
ASRS Report | 789088 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : inspector oversight : supervisor |
Qualification | technician : inspection authority technician : airframe technician : powerplant |
Experience | maintenance lead technician : 2 maintenance technician : 4 |
ASRS Report | 789087 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : published procedure |
Independent Detector | aircraft equipment other aircraft equipment : oil filter bypass |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | contributing factor : briefing performance deficiency : testing |
Supplementary | |
Problem Areas | Flight Crew Human Performance Maintenance Human Performance Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
I received a heads-up from maintenance (control) center that aircraft X was inbound to gate and had an oil filter bypass indication and an automatic shutdown of #2 engine. I debriefed flight crew. During debrief; we discussed the engine indications and performance. The crew left. I read the write-up and found the crew wrote up #1 engine. I conferenced with my supervisor. I told him the write-up is on the #1 engine and that during debrief of flight crew we didn't discuss engine #1 or #2 just the performance. Supervisor asked me to change the write-up to reflect #2 engine; which I did. I turned the aircraft over to the night shift lead. I told the lead of the logbook change to reflect technical operations system log. I picked up on the aircraft paperwork the following morning and closed out the aircraft log. I should have had the inbound flight crew called back for verification. Supplemental information from acn 789087: the lead went to the aircraft and debriefed the crew. After departing the aircraft with the logbook; the lead informed me that the write-up was for the #1 engine; not the #2 engine. I then called the engine desk at maintenance control and spoke to XXX regarding this development. He informed me that according to the logbook history; it was indeed the #2 engine and it shut down at 137 ft; not 500 ft. We made a few comments about the fact that the crew would not have had time to react at that phase of flight and ended the call. I then informed lead to change the write-up from #1 engine to #2 engine based on the information I received from the engine desk at maintenance control. No action was taken by myself; however; the aircraft had another indication 3 days later that resulted in an air return. The oil filter bypass was addressed again at that time for #1 engine. There were several instances of failed communication in this incident. My belief is the crew either failed to give the correct engine information to both the control center and maintenance control or they both misunderstood the information. When I called the maintenance control engine desk he either misread the information to me regarding which engine failed or I misunderstood him. And lastly; since the reliability of the crew was in question; I should have called them back to the aircraft and verified with them which engine had shut down. I also believe the technicians were not negligent in their actions; and they responded appropriately with the information they were given. I also responded with the belief that I had correct information as to which engine was indeed shut down. Callback conversation with reporter acn 789088 revealed the following information: reporter stated the lack of correct information compounded this situation. Even though the flight crew wrote-up #1 engine having the oil bypass filter; the engine did not initiate an automatic shutdown. The flight crew actually shut down #1 engine. Why the flight crew did this for an oil filter bypass indication while on approach is still unknown. Somehow; maintenance control; through ACARS and commercial radio; ended up believing #2 engine was the one that had an automatic shutdown. Reporter stated he knew something wasn't right; when he interrogated the #2 engine eec; and did not find any latch messages that would indicate an engine fault.
Original NASA ASRS Text
Title: A LEAD MECHANIC AND SUPERVISOR ARE INFORMED AN INBOUND B737-800 HAD AN OIL FILTER BYPASS INDICATION AND AN AUTO SHUTDOWN OF #2 ENG ON APPROACH AT APPROX 137 FEET.
Narrative: I RECEIVED A HEADS-UP FROM MAINT (CTL) CTR THAT ACFT X WAS INBOUND TO GATE AND HAD AN OIL FILTER BYPASS INDICATION AND AN AUTO SHUTDOWN OF #2 ENG. I DEBRIEFED FLT CREW. DURING DEBRIEF; WE DISCUSSED THE ENG INDICATIONS AND PERFORMANCE. THE CREW LEFT. I READ THE WRITE-UP AND FOUND THE CREW WROTE UP #1 ENG. I CONFERENCED WITH MY SUPVR. I TOLD HIM THE WRITE-UP IS ON THE #1 ENG AND THAT DURING DEBRIEF OF FLT CREW WE DIDN'T DISCUSS ENG #1 OR #2 JUST THE PERFORMANCE. SUPVR ASKED ME TO CHANGE THE WRITE-UP TO REFLECT #2 ENG; WHICH I DID. I TURNED THE ACFT OVER TO THE NIGHT SHIFT LEAD. I TOLD THE LEAD OF THE LOGBOOK CHANGE TO REFLECT TECHNICAL OPS SYS LOG. I PICKED UP ON THE ACFT PAPERWORK THE FOLLOWING MORNING AND CLOSED OUT THE ACFT LOG. I SHOULD HAVE HAD THE INBOUND FLT CREW CALLED BACK FOR VERIFICATION. SUPPLEMENTAL INFO FROM ACN 789087: THE LEAD WENT TO THE ACFT AND DEBRIEFED THE CREW. AFTER DEPARTING THE ACFT WITH THE LOGBOOK; THE LEAD INFORMED ME THAT THE WRITE-UP WAS FOR THE #1 ENG; NOT THE #2 ENG. I THEN CALLED THE ENG DESK AT MAINT CTL AND SPOKE TO XXX REGARDING THIS DEVELOPMENT. HE INFORMED ME THAT ACCORDING TO THE LOGBOOK HISTORY; IT WAS INDEED THE #2 ENG AND IT SHUT DOWN AT 137 FT; NOT 500 FT. WE MADE A FEW COMMENTS ABOUT THE FACT THAT THE CREW WOULD NOT HAVE HAD TIME TO REACT AT THAT PHASE OF FLT AND ENDED THE CALL. I THEN INFORMED LEAD TO CHANGE THE WRITE-UP FROM #1 ENG TO #2 ENG BASED ON THE INFO I RECEIVED FROM THE ENG DESK AT MAINT CTL. NO ACTION WAS TAKEN BY MYSELF; HOWEVER; THE ACFT HAD ANOTHER INDICATION 3 DAYS LATER THAT RESULTED IN AN AIR RETURN. THE OIL FILTER BYPASS WAS ADDRESSED AGAIN AT THAT TIME FOR #1 ENG. THERE WERE SEVERAL INSTANCES OF FAILED COM IN THIS INCIDENT. MY BELIEF IS THE CREW EITHER FAILED TO GIVE THE CORRECT ENG INFO TO BOTH THE CTL CTR AND MAINT CTL OR THEY BOTH MISUNDERSTOOD THE INFO. WHEN I CALLED THE MAINT CTL ENG DESK HE EITHER MISREAD THE INFO TO ME REGARDING WHICH ENG FAILED OR I MISUNDERSTOOD HIM. AND LASTLY; SINCE THE RELIABILITY OF THE CREW WAS IN QUESTION; I SHOULD HAVE CALLED THEM BACK TO THE ACFT AND VERIFIED WITH THEM WHICH ENG HAD SHUT DOWN. I ALSO BELIEVE THE TECHNICIANS WERE NOT NEGLIGENT IN THEIR ACTIONS; AND THEY RESPONDED APPROPRIATELY WITH THE INFO THEY WERE GIVEN. I ALSO RESPONDED WITH THE BELIEF THAT I HAD CORRECT INFO AS TO WHICH ENG WAS INDEED SHUT DOWN. CALLBACK CONVERSATION WITH RPTR ACN 789088 REVEALED THE FOLLOWING INFO: REPORTER STATED THE LACK OF CORRECT INFORMATION COMPOUNDED THIS SITUATION. EVEN THOUGH THE FLIGHT CREW WROTE-UP #1 ENGINE HAVING THE OIL BYPASS FILTER; THE ENG DID NOT INITIATE AN AUTO SHUTDOWN. THE FLIGHT CREW ACTUALLY SHUT DOWN #1 ENG. WHY THE FLIGHT CREW DID THIS FOR AN OIL FILTER BYPASS INDICATION WHILE ON APPROACH IS STILL UNKNOWN. SOMEHOW; MAINT CONTROL; THROUGH ACARS AND COMMERCIAL RADIO; ENDED UP BELIEVING #2 ENGINE WAS THE ONE THAT HAD AN AUTO SHUTDOWN. REPORTER STATED HE KNEW SOMETHING WASN'T RIGHT; WHEN HE INTERROGATED THE #2 ENGINE EEC; AND DID NOT FIND ANY LATCH MESSAGES THAT WOULD INDICATE AN ENG FAULT.
Data retrieved from NASA's ASRS site as of May 2009 and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.